Objective/Hypothesis: Variations in surveillance and staging of patients with high-grade, non-muscle-invasive bladder cancer affect outcomes following radical cystectomy. Specific Aims: (1)To identify whether variations in surveillance and staging of patients with high-grade, non-muscle-invasive bladder cancer exist;(2) to determine whether variations in surveillance and staging of patients with high-grade, non-muscle-invasive bladder cancer are associated with measured outcomes after radical cystectomy- length of stay, perioperative mortality, complications, and overall and disease-specific survival. Study Design and Methods: Using linked data from SEER-Medicare, we propose to evaluate adherence to established American Urological Association and the National Comprehensive Cancer Network guidelines for management of patients 65 years of age or older with high-grade, non-muscle-invasive bladder cancer. We will evaluate for adherence to surveillance and staging measures such as cystoscopy every six months, appropriate use of intravesical chemotherapy and immunotherapy, upper-tract imaging every two years, timely cystectomy, and greater than ten lymph nodes dissected at the time of cystectomy. We will determine whether these process-of-care indicators have a measurable impact on complications and survival after radical cystectomy. PUBLIC HEALTH RELEVANCE: If adherence to clinical quality indicators is significantly associated with the outcomes, then educational interventions may improve the delivery of care to those with bladder cancer. If, however, certain quality indicators are inconsequential, then tapering the current surveillance strategies may reduce the burden of health care costs without compromising health care quality